Eur J Anaesthesiol 2017; 34:471–476
ORIGINAL ARTICLE
Training in intraoperative handover and display of a checklist improve communication during transfer of care An interventional cohort study of anaesthesia residents and nurse anaesthetists Marion Jullia, Anaı¨s Tronet, Fabiola Fraumar, Vincent Minville, Olivier Fourcade, Xavier Alacoque, Yannick LeManach and Matt M. Kurrek BACKGROUND Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality. OBJECTIVES We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room. DESIGN Interventional cohort study. SETTING Single-centre tertiary care university hospital. PARTICIPANTS A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016. INTERVENTION Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week ‘baseline’ observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an ‘immediate’ second and finally a third (3 months later) observation period.
MAIN OUTCOME MEASURES A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: 1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item. RESULTS Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group’s scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n ¼ 42; ‘immediate’ 10.9 (9.4 to 12.4) n ¼ 27, P < 0.001]. This improvement persisted at 3 months without an increase in the mean duration of handovers. CONCLUSION Intraoperative handover training and display of a checklist in the operating room improved the checklist score for intraoperative transfer of care in anaesthesia. Published online 21 April 2017
Introduction Most preventable adverse events in medicine are because of communication errors, and more than half of these occur in relation to transitions of care. Hudson et al.1 found a 43% increase of in-hospital mortality and a 27% increase of major morbidity associated with intraoperative handovers between anaesthetists in cardiac surgery. Similar effects were observed by Saager et al.2 in general surgery and by Hyder et al.3 during colorectal surgery.
In recent years, there has been an increasing focus by the Joint Commission in the United States of America on improving handovers.4 Handover checklists seem to be an easy way to standardise oral communication and to reduce loss of information. Several well designed studies have shown their positive effect on postoperative handovers by anaesthetist to postanaesthesia care unit (PACU) nurses.5–7
From the Departments of Anaesthesia and Critical Medicine, University Hospital Toulouse, Toulouse, France (MJ, AT, FF, VM, OF, XA, MMK), McMaster University, Hamilton, Population Health Research Institute (YL); and University of Toronto, Ontario, Canada (MMK) Correspondence to Matt M. Kurrek, Department of Anaesthesia, University of Toronto, 123 Edwards Street, Room 1200, 12th floor, Toronto, ON, Canada M5G 1E2 Tel: +1 416 978 4306; fax: +1 416 978 2408; e-mail:
[email protected] 0265-0215 Copyright ß 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology. DOI:10.1097/EJA.0000000000000636 This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
472 Jullia et al.
Although the intraoperative period is equally critical, there have been relatively few studies on transfer of care in the operating room. Most of these studies are difficult to interpret due to methodological bias stemming from the fact that the observations were not blinded.8–13 In addition, the effect of handover protocols and checklists may be difficult to extrapolate to other countries, particularly when standardised communication is not yet a common part of everyday practice (currently the situation in France). We hypothesised that the implementation of intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room by increasing the number of items of information transmitted.
Methods The study received Research Ethics Board (REB) approval by the REB in Toulouse (no. 10-0116, dated 11 February 2016, Chair: Dr Nathalie Nasr, CHU Toulouse, Place du Docteur Baylac, Toulouse 31000 France, including a waiver for written consent, because the study was anonymous). All data recording was anonymous with regard to patient and anaesthesia team members. In preparation for the study, and following a review of the relevant literature, a checklist of 22 handover items was created and validated by a modified DELPHI method among anaesthesia residents and staff (a total of three iterations until consensus among 23 individuals).6,8 The interventional cohort study was carried out from January to May 2016 at the University Hospital in Toulouse (CHU Toulouse), which has two different hospital sites in the same city. Intraoperative handovers among residents and nurse anaesthetists were first evaluated simultaneously at the two sites over a period of 2 weeks at ‘baseline’. Following this initial evaluation, one site served as the ‘intervention’ site, in which an intraoperative handover training and display of the laminated 22item checklist (Table 1) at each anaesthesia workstation were implemented; the other site acted as the ‘control’ site, with no intervention. There were two further evaluations at both sites which followed the ‘baseline’ evaluation: ‘immediate’, over a period of 2 weeks just after training and display of the checklist; and at ‘3 months’, over a period of 1 week, 3 months after protocol implementation. All observations were blinded, meaning that none of the healthcare providers knew that the handover was being observed and scored. This was accomplished by putting the observers (two nurse anaesthetist students) in the operating room close to the anaesthesia team under a completely different pretext unrelated to the anaesthetic (verifying equipment or observing the surgery). At the end of the study, an anonymous satisfaction survey was carried out among the anaesthesia providers in the intervention site.
Eur J Anaesthesiol 2017; 34:471–476
Table 1
Content of the handover checklist
Preoperative Intervention (history of present illness, elective vs. emergency, etc.) Patient (name, age, sex, ASA status, etc.) Past history (medical, surgical, anaesthetic, family, etc.) Allergies Medications (anticoagulants, antibiotics, cardiac, diabetic, etc.) Team (anaesthesia, surgeon, nurses, etc.) Intraoperative Anaesthetic technique Induction Airway – Cormack/Lehane Equipment (vascular access, monitoring, etc.) In & Out (iv fluids, blood products, urine output, blood loss, etc.) Injections (neuromuscular blockers, PONV prophylaxis, narcotics, antibiotics, vasopressors, etc.) Remaining time Haemodynamic and respiratory stability Postoperative PACU (plan for emergence: extubation/intubation; lab, radiograph, regional, pain, etc.) Postoperative orders Disposition (ambulatory, floor, monitored bed, ICU, etc.) Miscellaneous Special clinical/study protocol OR planning (following case, set-up and materials, etc.) Documentation of transfer of care ASA, American Society of Anesthesiologists’ physical status; OR, operating room; PACU, postanaesthesia care unit; PONV, postoperative nausea and vomiting.
The handover training session consisted of two 1-h meetings and was offered at the intervention site after the first observation phase (‘baseline’) had been carried out, The sessions included a brief discussion of the literature and an introduction to the laminated checklist. Several mock handovers were then practised using simulated cases. No information was given about scoring of the handovers or about the study to avoid an observer effect. After the handover training sessions, the laminated checklists were permanently displayed in each operating room. Only handovers made inside the operating room (by nurse anaesthetists and residents) were scored. The handovers between attending anaesthetists could not be observed because they usually occur outside the operating room at unpredictable times and locations. Handovers between (or in the presence of) student nurse anaesthetists were also excluded because of the possible influence of the educational setting between student and teacher. The study duration was limited to 6 months (the length of the residents’ assignment period). There was no crossover of personnel between the two study sites. A checklist scoring tool was created, which added the individual score for each of the 22 items as follows: 1, if there was an error in communicating an item of information (e.g. stating a wrong allergy or wrong comorbidity); 0, if an item of information was unreported; 0.5, if an item of information was partly communicated; 1, if an item of information was communicated correctly (e.g. correctly stating all the patient’s allergies or comorbidities). The decision about which components were
Checklist for intraoperative transfer of care 473
The data collection was done by two student nurse anaesthetist evaluators using their smartphones. Study data were collected and managed using Research Electronic Data Capture tools hosted at Digital Life/Paul Sabatier University.9 The two evaluators had completed training using simulated handovers and confirmed 100% inter-rater agreement during a trial live observation in an operating room at a site that was not involved in the study. The primary outcome was the checklist score. Secondary outcomes were handover duration, handover documentation in the anaesthesia record, and satisfaction with the checklist and the handover training session. The study was planned such that a sample of 40 at baseline and 20 at follow-up would have 90% power at a ¼ 0.05 to detect a difference in mean scores of 2.7 or greater, if SD of the score was 3. All outcomes were assessed by site and time period. Mean, SD and 95% confidence interval (CI) for means were calculated for checklist scores. Differences between means for sites, times and their interaction were studied with analysis of variance (ANOVA), employing Tukey’s Honestly Significant Differences (HSD) test for post-hoc analysis. Median and inter-quartile range (IQR) were calculated for handover duration. Differences were compared with the Kruskal–Wallis rank sums test, using Dunn’s tests for post-hoc analysis. The proportion of handovers accompanied by documentation was calculated, and differences were evaluated using Fisher’s exact test. All P values were two-sided and statistical significance was determined using P less than 0.05. All calculations were undertaken using R statistical software package V3.2.5 (R Core Team (2016). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria).
Results A total of 204 handovers were observed over a 5-month period – 86 in the intervention site and 118 in the control site. Checklist scores at ‘baseline’ were similar with mean (SD) values of 7.6 (2.6) and 8.8 (3.2) for intervention and Table 2
Fig. 1 22 20 18 16
*
14
Score
reasonably expected to be transmitted in the case of several components constituting one item (e.g. multiple allergies or comorbidities) was left to the discretion of the trained observer and generally aligned with documentation on the patient record. The maximum score possible was thus þ22 points.
*
12 10 8 6 4 2 0 Control site Control site Control site Intervenstion Intervention Intervenstion ‘baseline’ ‘immediate’ ‘3 months’ site site site ‘baseline’ ‘immediate’ ‘3 months’
Intraoperative handover quality score. See text for details. Mean values. Bars represent SD. P < 0.001 compared with baseline, and between sites.
control site respectively, increasing to 10.9 (3.8) and 11.0 (2.2) for the intervention site immediately after intervention and 3 months after intervention, respectively; at the control site, the scores at these times remained similar to ‘baseline’ at 6.7 (2.6) and 6.6 (2.6). Figure 1 shows mean (SD) scores by site and time. ANOVA showed a significant site by time interaction effect (P < 0.001). Post-hoc testing with Tukey’s HSD showed significant increases in mean (95% CI) scores in the intervention group of 3.4 (1.3 to 5.4) immediately after and 3.4 (1.0 to 5.8) 3 months later (both P < 0.001). The control site showed decreases from ‘baseline’ of 2.1 (3.7 to 0.4) (P ¼ 0.007) and 2.2 (4.4 to 0.1) (P ¼ 0.064) for the corresponding time periods. Durations of handovers are shown in Table 2. The Kruskal–Wallis test, which included site, time and their interaction, indicated a significant difference between sites. Dunn’s post-hoc test was used for pairwise comparisons. At the intervention site, the duration of handovers did not increase after handover training and display of the checklist. Median (IQR) duration at ‘baseline’ was 2 (1 to 3) min; immediately after intervention, the duration was 1 (1 to 1.5) min, and 3 months later, it was 2 (2 to 3) min. Site comparison at matching times
Duration (min) of intraoperative handovers
Median (IQR) Baseline Immediate 3 months
3 (2 to 4) (n ¼ 47) 3 (2 to 3) (n ¼ 51) 2 (2 to 3.25) (n ¼ 20)
Control site Comparison with baseline P – 0.66 0.63
Median (IQR)
Intervention site Comparison with baseline P
Site comparison P
2 (1 to 3) (n ¼ 42) 1 (1 to 1.5) (n ¼ 27) 2 (2 to 3) (n ¼ 17)
– 0.62 0.10
